What have you been reading, hearing or TV viewing that has provoked some feelings of comfort or concern about what is happening in the world of medicine, medical care, treatment or science? Ethics is all about doing the right thing. Are you aware of any issues in medicine or biologic science which are being done right, could be improved or in fact represent totally unethical behavior?
Write about them here.. and I will too! ..Maurice (DoktorMo@aol.com)

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Friday, March 01, 2013

"DEATH PANELS": Do You Believe They Exist?

Hey! Do you remember,starting in 2009,the political fury, concern and cries about "Death Panels" in the United States as the Affordable Care Act ("Obamacare") was being debated? If you don't..where were you? Wikipedia has an excellent article on this topic to refresh your memory.

My understanding of what the public considers as a "death panel" would be a group of individuals not related to any specific patient but who becomes responsible to make a decisions as to what life-supportive treatment or other treatment would be allowed to be started or terminated for a patient. "Death" is used in the name since it is felt that death could well be the outcome of their decision. One way or another, it was this group "pulling the plug" on the patient's life-support.

An example of such a concern prior to the Affordable Care Act was the matter of the Texas statute Section 166.046 passed in 1999. The statute stated "If an attending physician refuses to honor a patient's advance directive or a health care or treatment decision made by or on behalf of a patient, the physician's refusal shall be reviewed by an ethics or medical committee. The attending physician may not be a member of that committee. The patient shall be given life-sustaining treatment during the review." The patient or patient's surrogate may attend the meeting and receive a written explanation of the decision reached. If the physician, patient or surrogate don't agree with the decision, then the physician must attempt to transfer the patient to another physician or institution who will agree with the decision or follow the request of the patient or surrogate. Life-supportive treatment must be continued for 10 days after the decision or prolonged by court action. Following the letter of the law, provides legal immunity to the physician and hospital's ethics committee if the patient dies. There has been many patient cases decided in this manner under this Texas law along with considerable controversy.

I can't speak for Texas law and behaviors, but we, in California, have a similar law in the Probate Code regarding following patients' instructions or decisions:

"Section 4735. A health care provider or health care institution may decline to comply with an individual health care instruction or health care decision that requires medically ineffective health care or health care contrary to generally accepted health care standards applicable to the health care provider or institution
Section 4736. A health care provider or health care institution that declines to comply with an individual health care instruction or health care decision shall do all of the following:
(a) Promptly so inform the patient, if possible, and any person then authorized to make health care decisions for the patient.
(b) Unless the patient or person then authorized to make health care decisions for the patient refuses assistance, immediately make all reasonable efforts to assist in the transfer of the patient to another health care provider or institution that is willing to comply with the instruction or
decision. (c) Provide continuing care to the patient until a transfer can be accomplished or until it appears that a transfer cannot be accomplished. In all cases, appropriate pain relief and other palliative care shall be continued."

Notice in the Code there is no mention of a final decision to be made by an ethics committee. An ethics committee would meet, however, to allow the patient or surrogate an opportunity to understand and counter the physician's view and for the committee, beyond moderating the meeting, to establish whether the physician's decision is appropriate with regard to current law and ethical consensus. The medical decision to reject the patient's request is solely that of the physician.

I might add, that in California, hospital ethics committees may participate in a similar way with regard to expressing current law and ethical consensus in cases where the physician intends to terminate life-supportive treatment in a patient who has had no Advance Directive, no present capacity to make medical decisions and not expected to recover that capacity and, after searching with due diligence unable to find any relatives or friends who could contribute to the understanding of the patient's desires.

Defending only hospital ethics committees, as a current member and former chairperson, based on what I explained above, I would reject the view that our committee is a "death panel". We, as a committee, have no capacity to make medical decisions about appropriate therapy for a specific patient. We can listen to all sides and explain what is ethical and legal. If the physician's view is ethical and legal, then, as a hospital ethics committee, we can support his or her decision.

But, finally, how about you? Do you think that "Death Panels" exist in our United States medical system? ..Maurice.

4 Comments:

Well I can only state that if you are on Medicare, death panels do exist, not by anyother means than doctors refuseing to accept Medicare reimbursal. This limits the type of care that can be had by those on medicare, as well as the best doctor for the case. America is the only civilized country in the world that does not have universal health care for its citizens. I feel sorry for the doctors that treat those on Medicare, they loose money on each patient. IT IS NOT RIGHT for them and it is NOT RIGHT FOR THE PATIENTS. J

J, you bring up an important issue regarding the practice within Medicare. Diminishing Medicare payment to physicians can definitely become a deadly behavior towards the further care of the Medicare population. The "panel" really represents the Congress and Administration who set the rules by law which dictates the cuts when they occur.

Although,a 26.5% cut in Medicare payment to physicians was halted by Congress for 1 year on New Years day 2013, the current "sequester" may nevertheless cut payment to doctors by 2%.

This thread, however, is about alleged "panels" who decide on what treatment should be offered and what treatment should be denied or removed regarding individual patients.. or as in the case of Oregon, a panel actually existed years ago in setting up criteria for what specific tests or treatments the state of Oregon would pay for under Medicaid...Maurice.

I believe there are death panels in this country, responsible for tens of thousands of deaths every year. They call themselves health insurance companies. These companies make decisions every day about who will live and die, and whether those who do live will have any quality of life. We have outsourced what should be a rational, meaningful discussion of the pros and cons of continuing treatment to corporations who profit from from the pain and suffering of others.

I have a lot of problems with the Affordable Care Act, but I never believed the nonsense about death panels as part of that legislation.

I said above that there should be meaningful conversations about the pros and cons of continuing treatment. From the discussions I have read here it sounds like efforts are made at that, at least in teaching hospitals. I think that is a very good thing. I must tell you that I think the patient or decision maker for the patient should be informed and involved from the moment it becomes clear a discussion like this is needed. As a family decision maker, I was not informed of decisions that were being made until I was ambushed with an emergency call, made a hurried trip, and was told after I made that trip that I needed to withhold a simple antibiotic from my father and wait for my father to die. I had been in touch with the hospital every day and no one bothered to tell me my father had stopped eating or other information that would have helped me and maybe him. They just wanted me to withhold the antibiotic and they were confused and upset with me when I refused to withhold the treatment. These doctors had no problem deciding my father should die, but they needed me to pull the trigger.

Shouldn't I have been included? My father was sitting up and talking the same day he was given the antibiotic, but he died a few months later. The decision not to tell me about his eating may or may not have led to his death. Maybe I could have visited before the crisis and convinced him to eat. Maybe I could have worked with the hospital to try some other things before it reached that point. Maybe, had everything been tried and I was assured of that, the withholding of the antibiotic might have been the humane thing to do. I will never know. This haunts me to this day, and it is one of the reasons I do not trust doctors. This "death panel" didn't include the person who had to make the decision to let him die.

It may sound like I am one of those people who would do anything to keep a person alive. Nothing could be further from the truth. Setting aside finances (and I wish we could), there are times when the pain and suffering caused by a treatment is worse than the disease. There are also times when it is inhumane to keep reviving a person, or to provide painful and invasive treatment for the sake of keeping a person breathing a few days. I saw what it was like when my grandmother was repeatedly revived. That was a long time ago, but I knew I wouldn't want that for me. I think it is entirely appropriate to have discussions about specific individuals and the ethics of different treatment choices. I also think there are times when doctors have to admit there is nothing they can reasonably do. Because of the insurance companies and even more because of the strong emotions whipped up by the political opposition to the Affordable Care Act, it seems to me even approaching the possibility of a sane approach to end of life decision making is difficult. In a more humane medical system, maybe it wouldn't have to be that way.

XYZ, you have a valid reason to be upset with the way you were treated with regard to decisions about your father. For patients who do not have the capacity at the point of their illness where decisions, some even life and death, need to be made, their surrogates (often family members) must be a part of the decision making process and must be given all the information necessary to act as the surrogate for the patient to be able to make appropriate and ethical decisions.

This process can take place in the form of a hospital ethics committee meeting. Hospital ethics committee meetings with the doctors and the other stakeholders including the patient or surrogate for the patient should not be looked upon as "death panels" but an environment for all the stakeholders to communicate with each other under the guidance of the committee and for the stakeholders to finally understand the facts and the views of each other so as to come to a final decision. It seems that an ethics committee meeting did not occur in your case otherwise you would have been comfortable with the outcome. ..Maurice.

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